The poor mental health status of Indigenous peoples globally is a result of historical and ongoing legacies of colonization and systemic disadvantage manifest in state policies and service provisions, purportedly designed to promote or restore health [
1]. In the Canadian context, past and ongoing Eurocentric policies have been implicated in rapid cultural change, forced assimilation, and dispossession. These policies have severed links between culture and identity and resulted in the criminalization and continued pathologization/problematization of cultural beliefs and practices. For example, the forced removal of Indigenous students from their families and communities to attend residential schools (1884–1996), where Indigenous languages and cultural expressions were banned, and where malnutrition and abuse were prevalent, has been implicated in multigenerational trauma [
2‐
5]. Combined, these have gravely undermined Indigenous communities’ capacity to be self-determining [
1,
6‐
10]. Multigenerational trauma has resulted in mental distress expressed through higher rates of posttraumatic stress disorder, depression, suicide, and substance use [
8,
11]. While concerted efforts are being undertaken to ameliorate these alarming outcomes, disparities in mental health outcomes continue to persist between Indigenous and non-Indigenous populations in settler-colonial nations [
12].
Primary health care (PHC) has been consistently heralded as a significant component of well-functioning health systems, leading to the promotion of population health and the prevention of disease, including mental health and illness [
13]. Calls to action have been made to improve healthcare inequity through reforms over the administration and delivery of PHC services. These calls have been articulated for decades through documents such as the historic Declaration of Alma-Ata in 1978 and the World Health Organization’s 2008 report,
Primary Health Care: Now More than Ever and the more recent Truth and Reconciliation Commission [
13‐
15]. A key feature of PHC is that it seeks to deinstitutionalize care and instead locate services in the community. When mental health care (MHC) is integrated with PHC services, it can potentially offer patient/family-centric holistic care, address treatment gaps, reduce costs, promote human rights by mitigating stigmatization and social exclusion, enhance access to services closer to families and communities, and produce positive mental health outcomes [
16].While a growing impetus to integrate MHC into PHC services is occurring globally, documented cases demonstrate that integration has been fraught with challenges. Challenges vary but are commonly characterized by fiscal constraints, organizational issues, availability of medical technologies and public health surveillance systems, and the cultural and technical competence of health professionals working with marginalized groups [
16].
Among settler-colonial nations such as Australia, Canada, New Zealand and the United States, reforms propose to better align mental health services with PHC principles, in the hope of responding more effectively to the needs of Indigenous peoples [
17‐
20], and to close the gaps that demarcate the shared experiences of health inequities reported for Indigenous peoples, when compared to their national counterparts. National rates of mental disorders among Indigenous peoples, which can result in self-medication and substance abuse, are not clearly known due to community variations, scarce non-standardized data, and the lack of an Indigenous identifier in national datasets. In Canada specifically, while a majority of First Nations report good mental health and balance, a significant proportion living within or outside First Nations communities experience distress or mental disorders and substance abuse at higher rates compared to the Canadian population [
21,
22]. To address this issue, the Truth and Reconciliation Commission recommended the development of holistic Indigenous healing centres [
15]. Indigenous nations have advocated for programs designed by Indigenous communities, and that reflect Indigenous perspectives on wellness and Indigenous treatment modalities [
8,
23‐
25].
The purpose of this study was to document the rates of hospitalization for a selection of mental health-related conditions for First Nations in British Columbia (BC) living across different jurisdictional and geographical locations compared to rural and urban BC residents, and explore the relationship between local access to PHC services and mental health outcomes among First Nations communities. BC was chosen because it offers a unique context to explore the research objectives given the variability of community sizes, remoteness and therefore access to mental health services, and diversity of First Nations based on languages, cultures, histories, and local economies. Currently, there has also been no work examining the optimal complement of PHC services required in BC rural and remote communities. While studies conducted elsewhere have documented barriers in access to appropriate PHC services for Manitoba on-reserve residents, which are associated with higher hospitalization rates [
27], it is unclear if this same pattern can be generalized to First Nations in BC. A key challenge facing BC First Nations communities is that they are relatively small, making access to PHC services much more challenging. As a result of a recent shift in governance over First Nations health in BC in 2013, generating empirical evidence to address these gaps in knowledge was identified as a significant research priority to inform and support mental health policy development and planning. These findings have relevance for international communities considering or undergoing PHC reforms to integrate MHC in response to the needs of Indigenous or rural communities.
Conceptual framework: access to health care services
Inadequate access to health care services has long been conceptualized as a determinant of health, reproducing disparities or inequalities in health outcomes between and within populations [
28]. While determinants of health are far-reaching to include genetics, lifestyle factors, socio-economic conditions, histories of oppression and physical environments [
29‐
31], we employ this conceptual framework to explore the differences of mental health outcomes as a function of access to PHC between First Nations and other BC residents, among First Nations living on and adjacent to First Nation reserves, and off reserve in BC communities. BC population level health data shows that mortality rates from medically treatable illnesses among status First Nations were higher compared to other BC residents (1.5 per 10,000 vs. 0.3 per 10,000), potentially signaling gaps in access to PHC [
32]. Our study focuses on mental health outcomes which we postulate can be improved by the provision of community PHC-based mental health services.
The need for PHC interventions can be defined by the capacity to benefit one’s health status from these interventions, which may occur in the form of enhancement, restoration, preservation or protection of an individual or community’s health [
33]. For this study, we have expressed outcomes as hospitalization for mental health-related ACSC. Also known as avoidable or preventable hospitalizations, ACSC are defined as diseases or conditions that, if managed in a timely and efficient manner through PHC services, could prevent the onset of illness, control acute episodic conditions, and improve the management of chronic conditions [
34]. Higher rates of ACSC suggest ineffective, unresponsive and/or barriers to access PHC services [
35]. These proxy indicators have been widely accepted and validated as a measure of access to PHC services compared to self-reported survey data which may lack scientific rigour [
35]. They are used by researchers and policy-makers for identifying gaps in the delivery of PHC and providing opportunities for targeting health care service interventions. To explore health disparities between First Nations and other Canadians and their link to PHC, other Canadian studies have successfully employed ACSC to suggest a need for investments in PHC in First Nations communities [
27,
36,
37].
Access to health care services
In BC, at the time that the data for this study was collected (1994/95 to 2009/10), the federal government funded a limited complement of PHC services on First Nations reserves. This system remains in place in all other Canadian provinces, but in 2013 health services for BC First Nations communities became the responsibility of the First Nations Health Authority, an organization mandated by First Nations Chiefs in BC to advance a shared vision of healthy, self-determining and vibrant BC First Nations, in full partnership with both federal and provincial governments, and Regional Health Authorities in BC [
38,
39]. The service environment described below continues to create confusion around service provision to First Nations communities in other Canadian provinces, but in BC the BC First Nations Health Authority (FNHA) has undertaken a program of service integration that is progressively transforming service delivery. Nonetheless the results of this study are still important in BC for priority setting in PHC re-structuring, and to the rest of Canada for general implications in serviced arrangements.
The complement of services offered in each First Nation community varies based on community size, level of remoteness and geographical proximity to provincial services (see Table
1). This approach, which is based on recommendations put forth by a 1969 study which conceptualized the responsibility of federal government as complementary to those provided under provincial jurisdiction [
40], failed to recognize the perpetually shifting jurisdictional complications between provincial and federal roles in relation to First Nations, and erroneously assumed that the provinces would eventually take responsibility for First Nations health [
41]. Although access to provincial services has shifted over time (notably through the closure of rural hospitals or reduction in the number of hospital beds in the 1990s) and new programs have been added periodically to adjust for shifting needs (including the transition from infectious diseases to chronic conditions), the framework has remained fairly static. Studies have shown that First Nation communities with access to a broader complement of community-based PHC have better outcomes [
27]. Still, other studies suggest that federal investments have failed to keep up with needs, resulting in local health services managing increasingly complex needs with dwindling resources [
42,
43]. Local PHC services vary in provisions across communities based on available services, hours of operation, and proximity to provincial facilities (Table
1).
Table 1
Definition of the sample
Nursing Station | 10 |
Health Centre | 12 |
Health Station | 47 |
No Facility | 56 |
Although some First Nations communities have no local access to federally-funded PHC because of their proximity to provincial services. Communities considered to have only reasonable access to health care in nearby communities are typically served by an on-reserve health station. Health stations are staffed by part-time non-resident nurses and resident part-time community staff offering screening and prevention services only. Health stations are generally located in smaller communities with year-round road access to a provincial point of care located close by (family physician, rural hospital, or a nursing station). In contrast, health centres are located in communities where the closest provincial facility is 2 h away. Services are provided 5 days per week, including emergency care, screening and prevention services. However, recruitment and retention issues can result in lapses in the provision of services at health centres, and road access is at times limited to unpaved, logging roads. Finally, nursing stations provide screening, limited treatment, prevention services, emergency care and treatment services on a 24/7 basis by nurses with an expanded scope of practice. Nursing stations are often located in larger and more isolated communities that are fly-in only, or those served by roads that are operational only in the winter.
In regards to MHC services specifically, three main federal programs have been established to provided mental health counselling, funded through different mechanisms [
44]. The Short-Term Crisis Intervention Mental Health Counselling (STCIMHC) provides for community support and counselling sessions at times of crisis (following suicides in a community, for example). Under this program, an individual can be eligible to up to a maximum of 15 one-hour sessions per mental health crisis over a 20-week period of from a counsellor approved by the First Nations and Inuit Health Branch of Health Canada (FNIHB), which funds on-reserve health services and approves qualified counselors (i.e. psychologists, social workers with clinical counselling orientation or mental health counsellors). All former Indian Residential School students and family members [see 2 for a detailed overview] can apply for cultural and/or emotional support or counselling under the Indian Residential Schools Resolution Health Support Program (IRS RHSP). In addition, all communities benefit from the National Native Alcohol and Drug Abuse Program (NNADAP), which provides primary prevention and support and coordinates referrals to residential treatment centres. Workers under these programs are generally community residents with variable levels of formal education. The program has historically been severely underfunded. Workers in most communities now provide support to families facing mental health and substance abuse challenges, with little additional training or support [
43]. Finally, the National Aboriginal Youth Suicide Prevention Strategy (NAYSPS) supports youth-centred suicide prevention interventions.
First Nations living off reserve are expected to access health care services under provincial jurisdiction similar to all Canadians, as defined by the
Canada Health Act,
1984 [
45]. Health care services deemed medically necessary are funded through federal transfers and provincial taxes, and the province administers services regionally. Concurrent to the regionalization of BC’s health care system in 2002, MHC had been undergoing a process of deinstitutionalization since 1998 to institute regionalized mental health community-based programming [
46]. This process, however, has occurred with little investment in community-based mental health services. Investments in First Nations-centric, culturally safe, trauma-informed mental health services that integrate Indigenous treatment modalities have not occurred.
Empirical studies examining the relationship between access to care for First Nations and health outcomes are limited. However, evidence suggests that access may not simply be a function of geographic accessibility but may be undermined by jurisdictional ambiguities, quality, transportation policies [
27,
47] and variable responsiveness. For example, despite the close proximity to health services in urban settings, utilization of specialist care by First Nations remains low [
48], suggesting that referrals are not being extended to First Nations to the same extent as to other Canadians, and/or that First Nations are reluctant to accessing specialists because of past histories of being discounted, racism and culturally unsafe care [
49‐
51]. Findings from studies investigating access to care for both Indigenous and non-Indigenous rural populations suggest that non-physician health professionals and telehealth services may be a viable option to improve access to care, given the constraints of physician supply in rural and remote communities [
27,
52,
53]. Finally, recent work by Kyoon-Achan and colleagues clearly shows that First Nations consider mental healthcare to be an important component of primary health care [
54]. The same authors have also shown that hospitalization for ACSC mental health conditions we included in this study are lower in communities with better access to primary healthcare [
55].